JJIAA-E3 Verification of Private School Student Eligibility for Participation in SAD #4 Co-Curricular Activities
NEPN/NSBA Code: JJIAA-E3 

VERIFICATION OF PRIVATE SCHOOL STUDENT ELIGIBILITY FOR PARTICIPATION IN SAD #4 CO-CURRICULAR ACTIVITIES 

A separate application must be received for each activity in which participation is desired. This form is used to verify eligibility and to approve/deny participation.

STUDENT INFORMATION

Student’s Name:

Student’s Date of Birth:

Grade in Private School:

Student’s Address:

Phone Number:

Parent/Guardian’s Name:

Private School Name:

Private School Address:

Private School Phone Number:

Private School Principal/Head’s Name:

Student is Applying for Participation in the Following Activity: ____________________

FOR CO-CURRICULAR ACTIVITIES

_____ Written application received ____________ (date)

_____ Student’s written agreement to comply with behavioral, disciplinary, attendance, and other rules applicable to all students in SAD #4

Student participation in the desired activity is ______ approved ______not approved

Decision by: _____________________________ (Name and Title) Date: ____________

Student/parent notified of decision: Date: ____________ Method: ______________

Adopted: January 10, 2012

M.S.A.D. #4